ACEs: When Social Ills Become Medical

To treat her young patients, Nadine Burke uses research on how adverse childhood experiences affect health.

When pediatrician Nadine Burke opened a clinic for California Pacific Medical Center in San Francisco’s Bayview Hunters Point, a neighborhood fraught with gang violence and low-performing schools, she started by offering the usual medical services to a poor population: tetanus vaccines, treatment for asthma and scabies, nutritional counseling to combat obesity. Then Burke read a study that linked “adverse childhood experiences” (ACEs)—including physical or emotional abuse, neglect and having an alcoholic or an imprisoned parent—with an increased risk of heart disease, chronic obstructive pulmonary disease (COPD) and other conditions. Once she dug into the literature, she found a small but compelling body of research that made similar connections. Realizing that the social problems she was seeing were central to her patients’ health, Burke began focusing on childhood trauma in her practice.

Denise Bosco for Proto

Q: How do ACEs affect health?

A: Repeated trauma causes the body’s fight-or-flight mechanism to go out of whack, which affects not only brain function but also the hormone and immune systems. For example, I was trying to figure out what triggered a five-year-old’s asthma. Her mom said, “You know, I did notice she had more trouble breathing after her dad punched a hole in the wall.”

Q: And how did your model help you translate that revelation into better care?

A: Before, I didn’t have the tools to react to a situation until it reached a crisis point. Then I could have called child protective services or handed Mom a piece of paper with a hotline number—the end. Now I address a patient’s social context as a way of practicing preventive medicine. I run weekly rounds where two physicians, two psychologists, two social workers and a clinic coordinator discuss each case. In the example of the five-year-old with asthma, the social worker might propose a home visit and the psychologist might recommend a program teaching parenting skills.

Q: You’ve said that what looks like a social situation is often a neurochemical situation.

A: If I see six kids from a school where there’s a lot of fighting and they all exhibit learning and behavioral problems, I don’t think, “Oh, the kids are just off the hook there.” I understand that their environment is affecting them biochemically. We know that stress and violence raise heart rate, blood pressure and levels of the stress hormone cortisol, and that they affect the immune system by changing helper T cell activity.

Q: What do you do with that knowledge?

A: I look for interventions that have demonstrated efficacy in reversing those effects. There’s wonderful data showing that stress reduction techniques, meditation and biofeedback, for instance, and other supplemental treatments, like child-parent therapy, can decrease heart rate, blood pressure and cortisol levels, and regulate helper T cells.

Q: The higher a child’s “ACE score,” the greater the health risks, you point out. But isn’t childhood trauma more complex than a number?

A: Yes, it is, but whether a patient’s relative risk of a disease is 260% or 240%, whether certain types of adversity weigh more heavily than others—that’s less important. We can still use this information to guide our management.

Q: What do high ACE scores mean for your patients?

A: Kids who’ve been exposed to multiple ACEs have statistically significant increases in obesity and in learning and behavioral problems. The latter is particularly high, and that’s not surprising. Studies have linked childhood abuse to changes in the volume of the hippocampus, which is involved in learning and memory, and stress has been shown to disrupt the balance of neurotransmitters, something that characterizes many behavioral disorders.

Q: You want all patients, not just yours, to be screened for ACEs. What will help accomplish that?

A: First, perception. Physicians will screen if they know that ACEs are a major risk factor for problems like hepatitis and heart disease—if you have seven or more ACEs, your heart disease risk is higher than if you smoke or have high cholesterol. Second, with an average of 15 minutes per clinic visit, you’re only going to do things you’re reimbursed for, so we need a reimbursement structure. Third, say you have a kid with four ACEs. How do you manage him? You know he’s at risk for COPD, heart disease and hepatitis, but that’s down the line. Do you check liver functions? Cholesterol? We’re building the Center for Youth Wellness to figure out best practices.

Q: Wouldn’t some argue that you’re overstepping your boundaries as a physician?

A: It is absolutely within my boundaries to evaluate and treat the root cause of disease. If I didn’t act, I wouldn’t be doing my job.